Scholarship & Sliding Scale Application

Personal Info

Full Name

Pronouns

Email

Phone

Request Type

What type of support are you requesting?

Sliding Scale

Scholarship

Not Sure

Financial Snapshot

How many people are in your household?

Estimated Monthly Household Income

Any special circumstances we should know about?

Personal Story & Service Needs

Why are you seeking support?

What type of service are you interested in?

Recovery Coaching

Family Coaching

Mentorship

Other

Preferred frequency or duration (if known)

Optional Demographics (Optional but helpful)

Share anything else you feel is important (optional)

Submission & Timeline

By submitting this form, you affirm the accuracy of the information provided. We review applications within 3–5 business days. If approved, we’ll contact you to discuss next steps and schedule a session that works for you.

Confidentiality Notice

All information is held in strict confidence. Our goal is to offer support with dignity, respect, and no judgment.